EnCase EAP Affiliate Partner Request Form

First Name

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Last Name

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Practice / Organization Name

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Primary Location / Address

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Additional Service Locations (If Applicable)

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Type of Services Offered

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Adults

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Adolescents

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Children

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Anxiety

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ADHD

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Trauma

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Stress Management

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Substance Use

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Other (please specify)

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If Other, specify here:

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Please upload a copy of your Current Resume and a Copy of State License and/or Certifications

Click to upload files

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